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NICE falls for Bait and Switch by acupuncturists and chiropractors: it has let down the public and itself

May 25th, 2009 · 58 Comments

First the MHRA lets down the public by allowing deceptive labelling of sugar pills (see here, and this this blog). Now it is the turn of NICE to betray its own principles.

The National Institute for Health and Clinical Excellence (NICE) describes its job thus

“NICE is an independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health.”

Its Guidance document on Low Back Pain will be published on Wednesday 27 May 2009, but the newspapers have already started to comment, presumably on the assumption that it will have changed little from the Draft Guidance of September 2008. These comments may have to be changed as soon as the final version becomes available.

The draft guidance, though mostly sensible, has two recommendations that I believe to be wrong and dangerous. The recommendations include (page 7) these three.

  • Consider offering a course of manual therapy including spinal manipulation of up to 9 sessions over up to 12 weeks.
  • Consider offering a course of acupuncture needling comprising up to 10 sessions over a period of up to 12 weeks.
  • Consider offering a structured exercise programme tailored to the individual.

All three of this options are accompanied by a footnote that reads thus.

“A choice of any of these therapies may be offered, taking into account patient preference.”

On the face if it, this might seem quite reasonable. All three choices seem to be about as effective (or ineffective) as each other, so why not let patients choose between them?

Actually there are very good reasons, but NICE does not seem to have thought about them. In the past I have had a high opinion of NICE but it seems that even they are now getting bogged down in the morass of political correctness and officialdom that is the curse of the Department of Health. It is yet another example of DC’s rule number one.

Never trust anyone who uses the word ‘stakeholder’.

They do use it, often.

So what is so wrong?

For a start, I take it that the reference to “spinal manipulation” in the first recommendation is a rather cowardly allusion to chiropractic. Why not say so, if that’s whar you mean? Chiropractic is mentioned in the rest of the report but the word doesn’t seem to occur in the recommendations. Is NICE perhaps nervous that it would reduce the credibility of the report if the word chiropractic were said out loud?

Well, they have a point, I suppose. It would.

That aside, here’s what’s wrong.

The Evidence

I take as my premise that the evidence says that no manipulative therapy has any great advantage over the others.  They are all more or less equally effective.  Perhaps I should say, more or less equally ineffective, because anyone who claims to have the answer to low back pain is clearly deluded (and I should know: nobody has fixed mine yet).  So for effectiveness there are no good grounds to choose between exercise, physiotherapy, acupuncture or chiropractic.  There is, though, an enormous cultural difference.  Acupuncture and chiropractic are firmly in the realm of alternative medicine.  They both invoke all sorts of new-age nonsense for which there isn’t the slightest good evidence. That may not poison your body, but it certainly poisons your mind.

Acupuncturists talk about about “Qi”, “meridians”, “energy flows”. The fact that “sham” and “real” acupuncture consistently come out indistinguishable is surely all the evidence one needs to dismiss such nonsense. Indeed there is a small group of medical acupuncturists who do dismiss it. Most don’t. As always in irrational subjects, acupuncture is riven by internecine strife between groups who differ in the extent of their mystical tendencies,

Chiropractors talk of “subluxations”, an entirely imaginary phenomenon (but a cause of much unnecessary exposure to X-rays). Many talk of quasi-religious things like “innate energy”. And Chiropractic is even more riven by competing factions than acupuncture. See, for example, Chiropractic wars Part 3: internecine conflict.

The bait and switch trick

This is the basic trick used by ‘alternative therapists’ to gain respectability.

There is a superb essay on it by the excellent Yale neurologist Steven Novella: The Bait and Switch of Unscientific Medicine. The trick is to offer some limited and reasonable treatment (like back manipulation for low back pain).  This, it seems, is sufficient to satisfy NICE.  But then, once you are in the showroom, you can be exposed to all sorts of other nonsense about “subluxations” or “Qi”.  Still worse, you will also be exposed to the claims of many chiropractors and acupuncturists to be able to cure all manner of conditions other than back pain.  But don’t even dare to suggest that manipulation of the spine is not a cure for colic or asthma or you may find yourself sued for defamation.  The shameful legal action of the British Chiropractic Association against Simon Singh (follow it here) led to an addition to DC’s Patients’ Guide to Magic Medicine.
(In the face of such tragic behaviour, one has to be able to laugh).

Libel: A very expensive remedy, to be used only when you have no evidence. Appeals to alternative practitioners because truth is irrelevant.

NICE seems to have fallen for the bait and switch trick, hook line and sinker.

The neglected consequences

Once again, we see the consequences of paying insufficient attention to the Dilemmas of Alternative Medicine.

The lying dilemma

If acupuncture is recommended we will have acupuncturists telling patients about utterly imaginary things like “Qi” and “meridians”. And we will have chiropractors telling them about subluxations and innate energy.  It is my opinion that these things are simply make-believe (and that is also the view of a minority of acupuncturist and chiropractors).   That means that you have to decide whether the supposed benefits of the manipulation are sufficient to counterbalance the deception of patients.

Some people might think that it was worth it (though not me).  What is unforgivable is not to consider even the question.  The NICE guidance says not a word about this dilemma.  Why not?

The training dilemma

The training dilemma is even more serious.  Once some form of alternative medicine has successfully worked the Bait and Switch trick and gained a toehold in the NHS, there will be an army of box-ticking HR zombies employed to ensure that they have been properly trained in “subluxations” or “Qi”.   There will be quangos set up to issue National Occupational Standards in “subluxations” or “Qi”. Skills for Health will issue “competences” in “subluxations” or “Qi” (actually they already do). There will be courses set up to teach about “subluxations” or “Qi”, some even in ‘universities’ (there already are).

The respectability problem

But worst of all, it will become possible for aupuncturists and chiropractors to claim that they now have official government endorsement from a prestigious evidence-based organisation like NICE for “subluxations” or “Qi”.  Of course this isn’t true.  In fact the words “subluxations” or “Qi” are not even mentioned in the draft report.  That is the root of the problem. They should have been.  But omitting stuff like that is how the Bait and Switch trick works. 

Alternative medicine advocates crave, above all, respectability and acceptance.  It is sad that NICE seems to have given them more credibility and acceptance without having considered properly the secondary consequences of doing so,

 

How did this failure of NICE happen?

It seems to have been a combination of political correctness, failure to consider secondary consequences, and excessive influence of the people who stand to make money from the acceptance of alternative medicine.

Take, for example, the opinion of the British Pain Society. This organisation encompasses not just doctors. It
includes
“doctors, nurses, physiotherapists, scientists, psychologists, occupational therapists and other healthcare professionals actively engaged in the diagnosis and treatment of pain and in pain research for the benefit of patients”. Nevertheless, their response to the draft guidelines pointed out that the manipulative therapies as a whole were over-represented.

Manipulation

The guidelines assess 9 large groups of interventions of which manual therapies are only one part. The full GDG members panel of 13 individuals included two proponents of spinal manipulation/mobilisation (P Dixon and S Vogel). In addition, the chair of the panel (M Underwood) is the lead author of the UKBEAM trial on which the positive recommendation for
manipulation/mobilisation seems to predominately rest. Proponents of spinal manipulation/mobilisation were therefore over-represented in the generation of these guidelines, which, in turn could have generated the over-optimistic conclusion regarding this intervention.

It seems that the Pain Society were quite right.

LBC 97.3 Breakfast Show (25 May 2009) had a quick discussion on acupuncture (download mp3 file). After I had my say, the other side was put by Rosey Grandage. She has (among other jobs) a private acupuncture practice so she is not quite as unbiassed as me).  As usual, she  misrepresents the evidence by failing to distinguish between blind and non-blind studies. She also misrepresented what I said by implying that I was advocating drugs. That was not my point and I did not mention drugs (they, like all treatments, have pretty limited effectiveness, and they have side effects too). She said “there is very good evidence to show they (‘Qi’ and ‘meridians’] exist”.  That is simply untrue.

There can’t be a better demonstration of the consequences of falling for bait and switch than the defence mounted by Rosey Grandage. NICE may not mention “Qi” and “meridians”; but the people they want to allow into the NHS have no such compunctions.

I first came across Rosey Grandage when I discovered her contribution to the Open University/BBC course K221. That has been dealt with elsewhere.  A lot more information about acupuncture has appeared since then.  She doesn’t seem to have noticed it.  Has she not seen the Nordic Cochrane Centre report? Nor read Barker Bausell, or Singh & Ernst?  Has she any interest in evidence that might reduce her income?  Probably not.

Where to find out more

An excellent review of chiropractic can be found at the Layscience site. It was written by the indefatigable ‘Blue Wode’ who has provided enormous amounts of information at the admirable ebm-first site (I am authorised to reveal that ‘Blue Wode’ is the author of that site). There you will also find much fascinating information about both acupuncture and about chiropractic.
I’m grateful to ‘Blue Wode’ for some of the references used here.

Follow-up

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Tags: acupuncture · Anti-science · antiscience · Back pain · badscience · Bait and switch · BBC · British Chiropractic Association · chiropractic · chiropractor · Human resources · management bollocks · MHRA · NICE · Open University · Politicians · regulation · Rosey Grandage · science · Skills for Health · subluxation · Trinity College Dublin

58 responses so far ↓

  • 1 Dr Aust // May 25, 2009 at 19:28

    There is also the question of precisely who gets to be the representative of there “professions” on the Guideline Group – see my comments about which Chiropractor one might choose over at Lay Scientist, which I reproduce here:

    I agree that you would expect representatives of these professions (and I am using the word they prefer in an attempt to be non-judgemental) to be there on that “stakeholder” basis – but I find the choice of actual people interesting.

    It is one thing to choose, say, a manipulative therapist with a clear commitment to evidence-based practice, and some history with the NHS. I am sure you could find such people, like blogger and osteopath Jonathan Hearsey. You might also go for someone with demonstrable experience in grading evidence in an academic setting.

    It is another thing, arguably, to choose a kind of “shop steward” figure – like a past President of a chiropractic professional association – who you might say has a clear vested interest in defending any and all actions of his chosen profession. I am somehow searching for an analogy between putting Peter Dixon on the NICE Back Pain Guideline group to represent chiropractic, and having the outgoing House of Commons Speaker on a group investigating MPs expenses claims, and recommending new ways to police expenses. It is clearly possible, and may even be what happens. But… I wonder who thinks it is the best way to get at the truth?

  • 2 Dr Aust // May 25, 2009 at 19:39

    BTW, Mrs Dr Aust, who in her speciality sees an awful lot of chronic lower back pain, practically spat her cornflakes over the breakfast table when I showed her the Absurder’s story on the guidelines.

    “Up to NINE sessions?” she said “You must be !**!!*! joking. Three sessions, absolute maximum.”

    The point, in essence, being that if the intervention is an elaborate placebo to help get a fearful and “blocked” patient – one who perhaps refuses to take painkillers – up and mobile, you don’t need more than a session or two to get the magic expectation effect.

    “Up to nine”, though, will potentially do wonders for the spinal manipulators’ bank balances. Though not for the NHS budget.

  • 3 fiona B // May 26, 2009 at 22:41

    You are so bitter and ignorant!!! Perhaps you should have a good acupuncturist/chiropracter/osteopath work on you? or perhaps all 3 at the same time.
    They would fix you!!

    Your ideas would be what exactly?? more pills!!

    So exercise and a non drug approach are a bad thing in your eyes??

    you talk of libel action against certain individuals, Doctors are not above this… Harold Shipman.

    “Up to NINE sessions?” she said “You must be !**!!*! joking. Three sessions, absolute maximum.”

    Patients are welcome to wait upto 18weeks on the NHS for physiotherapy or return to the GP for repeat presciptions. This gives them constipation, so they are then prescribed laxatives for the side effects of the pain killers.

    MPs expenses!!! GPs expenses!!
    NHS doctors hit the slopes on an ‘education course’ that cost the taxpayer £400,000 this undoubtedly did wonders for the doctors bank balances.

  • 4 David Colquhoun // May 26, 2009 at 23:11

    fiona B

    I don’t think you read what I said. I said nothing about drugs and I don’t advocate them because I think their effectiveness is limited, and the danger of side effects is far from negligible if taken for a long time.

    What I actually said was that, since exercise and physiotherapy seem to be as effective as chiropractic and acupuncture, why not stick to exercise and physiotherapy. There is no need to give credence to the mystical baggage that comes along with chiropractic and acupuncture,

    It is true that waiting lists (in all areas) can be long. Perhaps they would be shorter if the NHS stopped wasting money on magic medicine and stuck to the real stuff.

    The fact of the matter is that low back pain is an unsolved problem. In most cases the origin isn’t known, and none of the treatments are very effective. I would have preferred it if NICE (and chiros) were a bit more open about that.

    Perhaps you should have mentioned that unwelcome fact. But then we all know that lack of critical self-appraisal is a defining characteristic of the alternative world of make believe medicine.

  • 5 neoconnell // May 27, 2009 at 09:08

    The NICE recommendation is a blow to reason. One of the NICE big cheeses (I forget his name) suggested on the Today programme that access to these therapies would prevent the development of severe persistent back symtoms, but I am aware of no evidence that directly suggests this. You would think that he might know a thing or 2 aboyt how to avoid misrepresenting evidence, but there you go.

    Fiona – your comments offer a useful window to the world of CAM. What a surprise to learn that acupuncture not only helps back pain but is also a panacea for ignorance and bitterness!

  • 6 mcassidy // May 27, 2009 at 13:04

    Hi David,

    I’m sorry no-one has managed to cure your back pain yet; you seem to have focussed a lot of energy on finding a way to express your unhappiness about it.

    Your site is very well put together, and I’m certain you believe in what you say. As a chiropractor I find it interesting to see how vehemently some dislike my profession, as from my perspective I have seen countless people’s lives transformed with help from the care they have received.

    It is true that there is no “one size fits all” solution for back pain, but there certainly is good evidence for the use of chiropractic on several conditions, low back pain included. The area I am interested in particularly is the link between misalignment from the ideal spinal curvature and chronic pain, which there is both good evidence and sound engineering theory for.

    I practice in Brighton; you would be most welcome to come down and visit our clinic and see the work we are doing here; perhaps we can learn something from each other.

    Yours in Health, Mike

  • 7 fiona B // May 27, 2009 at 13:07

    In response to David

    ”It is true that waiting lists (in all areas) can be long. Perhaps they would be shorter if the NHS stopped wasting money on magic medicine and stuck to the real stuff.”

    ‘Stopped’ is this because the NHS have spent SO much money already that could have sent to the physio dept? NO.

    The NHS clearly requires help. These private industries do very well already and it is clearly not because ill informed people go to see them. They do get results, despite what you believe.

  • 8 puzzlebobble // May 27, 2009 at 17:52

    @fionaB
    “They do get results, despite what you believe.”

    Really, that’s not what the research I’ve read says. However I’m always happy to be proved wrong. Please show me the evidence on which you base your claims.

    @mcassidy
    “from my perspective I have seen countless people’s lives transformed with help from the care they have received.”
    How do you know their lives wouldn’t have got transformed without your intervention?
    How do you know that the benefit wasn’t a placebo effect?
    You would surely agree that you are not an objective witness?

  • 9 martinbudden // May 27, 2009 at 18:28

    David,

    you say: “All three choices [spinal manipulation, acupuncture, structured exercise program] seem to be about as effective (or ineffective) as each other…”

    I think it’s a bit unfair to lump structured exercise programs in with spinal manipulation and acupuncture.

  • 10 neoconnell // May 28, 2009 at 07:41

    An interesting an revealing contradiction in the NICE guidelines that a friend just spotted. Spinal injections are (correctly) not recommended as the evidecne shows that they are not superior to placebo. But acupouncture…

    It seems only conventional medicine has to prove itself to a genuine standard.

  • 11 Lindy // May 28, 2009 at 09:50

    Yes, as usual there is one law for the real world and another for woo, though how this wriggled into an organisation like NICE is a mystery.

    On the argmuent (if it can be called that) of the ‘it works therefore it must be real’ there was an intereesting comment on More 4 News just before DC was on yesterday (May 27th). A woman had had low back pain and when she started going for acupuncture it got better. She still goes for her treatment and has been doing so since 1991. Very effective isn’t it?

    Prime example of the effectiveness of dodgy nonsense in lining pockets. This decision by NICE is just another way of farming out NHS work to private pockets.

    Also how will GPs identify the quacks (er, sorry, ‘therapists’) that they should recommend? It is bad enough that this has to be asked, but then to find that some GPs welcome the recommendation from NICE is cause for further alarm.

    And who is responisble for insurance if, say, there is a serious injury resulting from unproven therapies? Given the nature of govt contracts with private firms in public services, my guess would be that the GP and the NHS would be held to account.

    More mess – more of the anything goes culture.

  • 12 Muscleman // May 28, 2009 at 15:27

    The local NHS up here in Dundee has a triage set up for the Orthopaedic dept. It’s run by the physios, if you have an ache or pain you pitch up and they put you back together. They helped my back with some minor manipulation but what the major reason for me is lack of exercise and bad posture. I need to be active. I can’t lie in bed of a morning or I will pay for it.

    The manipulation did not have a long term effect, what it did do was relieve the pain for long enough to allow me to do the necessary exercises. I do pressups for the one between my shoulder blades and straight back situps for the lumbar one. They act as the warmup just before a run, the pressups were started to stop my shoulders aching on a long run, so they are a two for one.

    You have my sympathy David as a fellow distance runner. Provided I do my exercises I get nae bother from it on long runs

  • 13 Dr Aust // May 28, 2009 at 17:08

    Is anyone getting deja vu from the last time we discussed all this back in the Autumn? it was following a post about HR promoting various kind of quackeries, but much of the earlier part of the subsequent thread still seems relevant.

    The NICE guidelines do seems to be a rather feeble fudge. I can see why the Govt would like to paper over shortages of physios doing specialist back-strengthening exercises by “referring” out to the thriving Woo-sector (cf independent surgical treatment centres), but I am disappointed that NICE has gone along. Too many vested interests, methinks.

    Anyway, the wording suggests that individual GPs will get to carry on with whatever they prefer, which is perhaps the universal get-out clause. So I guess the “Woo-friendly” ones will carry on plugging Woo, while the more evidential ones like Dr Crippen do not. It will be interested to see what the GP magazine Pulse has to say.

  • 14 malucachu // May 28, 2009 at 18:59

    Some thoughts from an NHS physiotherapist.

    The NICE guidelines propose treatments that have very weak evidence to support their use within the NHS. They are also over prescriptive and the dosages proposed seem to have been reached arbitrarily. The guidelines undermine evidence-based practice, clinical reasoning and professional autonomy.

    In defence of the NICE team, the guidelines probably didn’t allude to subluxations because the vast army of manipulators (GPs, physiotherapist and osteopaths) do not use this nomenclature. Only a small number of chiropractors do. Manipulation is not the reserve of chiropractors, whatever arcane language they may use.

    The acupuncture does worry me greatly. Medical acupuncture (i.e. a non-traditional Chinese approach) may generate neurohormonal changes that might modulate pain, but no-one knows how clinically potent these events are.

    However, many NHS and private practitioners buy into the Qi concept of traditional acupuncture and it seems wholly inappropriate for this quasi-religious concept to be forced on to the public.

    By the way David, physiotherapy is a profession not a treatment.

  • 15 NICE fiasco, part 2. Rawlins should withdraw guidance and start again // May 28, 2009 at 19:32

    […] sc_project=233721; sc_invisible=0; sc_partition=0; sc_security=””; ← NICE falls for Bait and Switch by acupuncturists and chiropractors: it has let down the public and i… […]

  • 16 David Colquhoun // May 28, 2009 at 21:07

    Malacachu
    Thanks for that comment. It’s always good to hear from people who at the sharp end.
    th
    The point you make about ‘subluxations’ is really the same point as I was making. That sort of stuff will come along with (many of) the chiropractors> it is one of the secondary consequences that the guidance group chose to ignore, That is the bait and switch approach.

    Sorry about “professionals”. It is a word I have tended to avoid, ever since Lord Hunt (while he was at the Department of Health) referred to ‘psychic surgery’ as a profession. I’m a single channel biophysicist by trade, myself.

  • 17 Muscleman // May 28, 2009 at 22:09

    Anyway the thing about humans and back pain is just evidence that we are not fully adapted to bipedalism yet. We may never be of course since our only sort of adapted backs do not seem to be a limit on our specie’s ability to procreate seeing as there are so many of us now. Nothing to select on then is there?

    For eg we could have less compressible intervertebral discs.

  • 18 malucachu // May 29, 2009 at 08:47

    Sounds like you are a bit dismissive of physiotherapy as a profession. Sometimes I feel that some of what we do is as about as useless as psychic surgery.

    However, a fundamentalist view of the world inevitably reduces everything in pursuit of an agenda, however honorable that agenda may be.

  • 19 David Colquhoun // May 29, 2009 at 09:57

    malucachu
    I spent most of Wednesday, and this post + the next one, saying that manipulation by physiotherapists and exercise were what should be funded. not the mystical stuff. I feel you are perhaps being a bit oversensitive. I could not have been more clearly on your side.

  • 20 malucachu // May 29, 2009 at 10:15

    I apologise. I thought you were throwing the baby out of the bath water.

  • 21 Blue Wode // May 29, 2009 at 10:42

    @ Dr Aust

    Here’s what Pulse has to say:
    http://www.pulsetoday.co.uk/story.asp?sectioncode=23&storycode=4122799

    The first person to comment on that article doesn’t seem to realise that it’s not uncommon for chiropractors to manipulate the cervical spine even when a problem is confined to the lower back.

  • 22 NeuroLogica Blog » The NICE Fiasco // May 29, 2009 at 13:15

    […] David Colquhoun discusses this issue well. Patients may be referred to a chiropractor for uncomplicated low back pain, and then be hit up for treatment of their asthma, or to bring their child in to treat the colic. In fact, to demonstrate this he called a couple of chiropractic offices posing as a patient and they were happy to offer treatment for asthma and colic, and to assess him for whatever else might be ailing him. […]

  • 23 LC1 // May 30, 2009 at 19:28

    As a Uk based chiropractor it is interesting to note the comments here.

    I treat muscloskeletal problems. I don’t diagnose subluxations, my diagnoses for mechanical back pain are more likely to describe biomechanical dysfunction of the facet joints or discs. If I treat low back pain I would not usually treat the cervical spine (although a number of my osteopathic colleagues do!). In fact chiropractors have been disciplined (quite rightly) by the GCC for treating inappropriate areas of the spine without clinical justification.

    I think the subluxation arguement should be put into context. This approach to chiropractic diagnosis has not been taught in UK colleges for over 20 years. I think that it is an inappropriate term that confuses (you). My feeling is that terms such as spinal restriction, dysfunction or fixation are probably more appropriate (physio and osteos use these and others).

    I believe that most UK based chiros are committed to evidence based practice. I do not see chiropractic as a type of treatment, but rather a profession capable of using a range of techniques. These may include spinal manipulation, mobilisation, soft tissue techniques, acupuncture, exercise rehabilitation and patient education. The evidence for these techniques is comparable when used by chiropractors, osteopaths or physiotherapists. Incidently, look at the evidence base for osteopathy or note the number of physios or pain clinics using non EBM and you may be quite surprised.

    I think that being a skeptic is healthy but I have to be skeptical of the motives behind the majority of comments that I read. I note that most are posted by a small number of non-clinical academics. If you really want to influence our profession you should do your research and engage with us in a professional manner rather than just sniping at us.

    By the way my children have all been vaccinated.

  • 24 David Colquhoun // May 30, 2009 at 20:52

    LC1

    Thanks for writing. I have heard (off-line) from another chiropractor with views much like yours. As I have said, chiropractic encompasses a wide range of views and practices, and the more rational wing that you seem to represent is obviously far more acceptable than the barmpot wing.

    I notice that you say

    “In fact chiropractors have been disciplined (quite rightly) by the GCC for treating inappropriate areas of the spine without clinical justification.”

    I wonder then, what you think about what I was told about the treatment of colic and asthma by the first two chiropractors whom I phoned last week. Both of them, incidentally, worked in practices belonging to the group run by the chairman of the GCC (and member of the NICR guidance group), Peter Dixon. May I assume that you’ll be submitting a complaint to the GCC?

    I think also that you spoil your case a bit by saying that you also use acupuncture. Have you read Bausell’s book, I wonder.

    I’m not sure what motives you are attributing to critics like me. It certainly isn’t a defence of pharmacology (still less of Pharma) since I pointed out that drugs are as much of a failure in this area as all the rest. It doesn’t seem to occur to people that I might spend all this time because of an interest in distinguishing the true from the false. Now I no longer have to do administration or teaching, there are worse ways to spend time.

    Neither is it fair to accuse people like me of failing to do the research. Usually when talking to alternative practitioners, I find that they have rarely read the original literature, and often have not got sufficient knowledge of statistical inference to interpret it when they have read it.

    As for engaging in a “professional manner”, I’ve tried it and it doesn’t work. If you write letters to the proper authorities about degrees in homeopathy all you get is pompous replies that amount to saying “bugger off”. If, on the other hand, you reveal publicly that they are teaching students that “amethysts emit high Yin energy“, you can have an effect.

    From my point of view, it is hard to see why all manipulative people don’t form a single group. The evidence would still be thin, but at least the mystical gobbledygook would be gone forever.

  • 25 LC1 // May 30, 2009 at 23:01

    David

    I am pleased that other chiropractors have expressed similar views as actually I know that this moderate approach is far more common in the UK than your blog would suggest particularly amongst UK-trained chiropractors.

    In my practice I choose not to treat colic, patients normally see a cranial osteopath. Where I have treated patients with asthma I would only want to address issues of thoracic biomechanics (in a similar way to respiratory physio) and would not claim to treat the underlying inflammatory process and would certainly recognise the importance of the patients receiving approprate medical asthma management.

    On acupuncture, I have read the evidence review conducted by NICE (not as convincing as the evidenec for manipulation). I utilise medical acupuncture (no Yin, or meridians) that is most likeley to be a form of trigger point therapy or dry needling. This appraoch is used by my local pain consultant and physio. I see it as an adjunctive therapy best integrated into other management.

    The reason I accuse you of not having researched your subject is that as a chiropractor I do not recognise my profession from the descriptions perpetuated on your (and other) blog(s).

    Maybe I am being unfair to you, but just as you describe a “barmpot wing” the same is true of many bloggers.

    Professionalism is important. I often see throw away comments on the blogs or in the news that are either simply offensive or greatly misrepresent evidence that seem to be aimed more at stirring up public opinion than encouraging rational scientific debate. This approach is unlikely to be acceptable to “the proper authorities” and ultimately undermines your arguements.

    However, rather than bashing the whole chiropractic profession a more measured approach is likely to find common ground with elements of the profession.

    Your final point is interesting and in some ways quite appealing. My profession is relatively young and is evolving rapidly with the majority of chiropractors (in the UK) wanting to improve standards and embrace EBM. This is a natural process that other professions like medicine have gone (or are still going) through.

  • 26 David Colquhoun // May 31, 2009 at 08:26

    LC1
    I notice that you chose not to respond to my questions about Bausell’s book, or my questions about what chiropractors told me on the phone.

    Worse, though, I’m afraid that you have rather blown your own case for being part of rational 21st century medicine by saying that you’d refer patients to a “cranial osteopath”. I can only assume that your research hasn’t extended even as far as the columns of the Guardian. The Badscience column revealed in simple terms why “cranial osteopathy” is mystical bunk.

  • 27 Blue Wode // May 31, 2009 at 08:28

    LC1 wrote on May 30, 2009 at 11:01 pm: “I do not recognise my profession from the descriptions perpetuated on your (and other) blog(s).”

    That suggests that you are not aware of the results of a recent survey of the scope of chiropractic practice in the UK which revealed that traditional chiropractic beliefs (chiropractic philosophy) were deemed important by 76% of the respondents, with a further 63% considering subluxation to be central to chiropractic intervention.
    http://tinyurl.com/599vfs

  • 28 LC1 // May 31, 2009 at 12:52

    David

    I have not read Bausell’s book but I will. As I stated though I have read the NICE guidance (and the reviewed literature) that is aimed at clinicians.

    I did discuss my views on asthma management.

    As for colic, chiropractors, osteopaths and some physios treat this condition using a range of techniques including spinal mobilisation, massage, nutritional advice and parental reassurance. This seems appropriate as there are studies showing effectiveness of this type of management as I am sure you are aware.

    On the complaints question, I am sure you would not feel that complaining about the physio using electro therapy or the pain consultant using facet joint injections for low back pain is appropriate yet both of these procedures are now considered not to be evidence based. This approach is clearly not the way forward.

    You have misinterpreted my comments, I do not, and probably never would, refer patients to cranial osteopaths but, in my experience, this is often the choice that people make or interestingly what is recommended by our local GPs.

    I have read the Guardian columns that you mention. whislt they are interesing I do not believe they represent an objective source of primary research data.

    As for the other comments, I am aware of the survey mentioned, a weakness of this study was that it was not entirely representative of the profession. Also to form a definitive view, on how chiropractic is practiced from a survey of this nature and small sample size is inappropriate. I suspect that if you ask any profession whether their beliefs and philosophy were important you would get a similar response.

    On subluxations, I have already stated that this term is not these days used as a diagnosis and is not taught in UK colleges as such. The term is most often used to describe joint restriction/fixation and in my opinion this is confusing because of it’s medical meaning.

    Conversations like this could go on and on. As I stated before, professional engagement (without the sniping) has got to be the appropriate way forward. Perhaps consider putting effort into facilitating further research studies that ultimately will have greater influence with the “proper authorities”.

  • 29 Blue Wode // May 31, 2009 at 17:23

    LC1 wrote on May 31, 2009 at 12:52 pm: “As for the other comments, I am aware of the survey mentioned, a weakness of this study was that it was not entirely representative of the profession. Also to form a definitive view, on how chiropractic is practiced from a survey of this nature and small sample size is inappropriate.”

    That seems to be an over-optimistic viewpoint. In the UK, according to Edzard Ernst and Peter Canter, the influence of the `vitalists’, who insist that spinal manipulation is a panacea, is growing. See the last (referenced) letter in this link:
    http://tinyurl.com/mzgfwd

  • 30 LC1 // May 31, 2009 at 18:50

    Blue Wode…

    My view point is not based on optimism but experience and observation of UK based chiropractic practice.

    Vitalism, in my opinion, is essentially an outdated, outmoded model of chiropractic that is not taught in UK colleges and is not practised by many UK trained and UK based chiropractors. This approach has had some influence in the UK however.

    The article by Ernst and Canter that you refer to references a comment from a chiropractor on the make up of the GCC in 2002. Hardly a good source of information on the rise of vitalsim. You may know that GCC members are now selected by the appointments commission, a process based on competencies and experience. This should ensure that a vocal minority does not have an unnecessarily large influence on my profession. In addition the GCC now has greater lay representation.

    As I said before we are seeing evolution of the profession.

    I also suggest that with chiropractors taking a greater role in the mainstream management of low back pain (according to NICE) we will see a reduction in the number of “vitalist” chiropractors. So maybe there is room for optimism.

  • 31 Blue Wode // May 31, 2009 at 20:01

    LC1 wrote on May 31, 2009 at 6:50 pm: “Vitalism, in my opinion, is essentially an outdated, outmoded model of chiropractic that is not taught in UK colleges and is not practised by many UK trained and UK based chiropractors.”

    Are you sure about that? The McTimoney College of Chiropractic, which represents at least a quarter (500+ chiros) of the UK chiropractic profession, claims that:

    Quote
    “By correctly training the hands as an instrument of innate intelligence, healing can be encouraged to take place by the detection and correction of bony subluxations…”
    http://www.mctimoney-chiropractic.org/mca_objectives.htm

    That seems pretty vitalistic to me.

    LC1 wrote on May 31, 2009 at 6:50 pm: “The article by Ernst and Canter that you refer to references a comment from a chiropractor on the make up of the GCC in 2002. Hardly a good source of information on the rise of vitalsim.”

    Then perhaps this is a better source:
    http://www.united-chiropractic.org/modules/content/index.php?id=4

    LC1 wrote on May 31, 2009 at 6:50 pm: “You may know that GCC members are now selected by the appointments commission, a process based on competencies and experience. This should ensure that a vocal minority does not have an unnecessarily large influence on my profession. In addition the GCC now has greater lay representation. As I said before we are seeing evolution of the profession.”

    Or some might say we are seeing a more convincing smokescreen behind which quackery can flourish (for the most part unchecked).

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  • 33 mcassidy // Jun 9, 2009 at 14:53

    Still some interesting points being made on here, quite nice to see civility has generally been maintained.

    Puzzlebobble asked me: “How do you know their lives wouldn’t have got transformed without your intervention?
    How do you know that the benefit wasn’t a placebo effect?
    You would surely agree that you are not an objective witness?”

    I don’t want to get too philosophical, but no, I am in no way an objective witness to my life or the world around me. Nor is anybody.

    In so many cases I’ve seen people with a long history of pain and disability experience dramatic improvements in pain rating and functional ability after having chiropratic care. When that is the only thing they have changed and their history is of constant chronic pain, then I think it is fair to suggest that chiropractic was instrumental in their transformation, yes.

    The placebo idea I find fascinating.. it’s often just brushed off as a trivial notion that “it’s all in one’s head” and therefore the therapy didn’t actually work. But that dismisses the grander concept that our mind influences our healing potential in a far greater way than we presently understand.

    The power of hope and suggestion IS important. It’s not at all what chiropractic is about, but it is an important tool that all good doctors (whatever discipline) use. Seeing someone who’s been taught to be resigned to chronic pain (ie. a lifetime of meds) actually rise above that and be well is a joy and a privilege that I love about my profession.

    The invitation’s still open by the way David. That also applies to any of you who’d like to come and visit a chiropractic clinic and get some first hand experience of what it’s about. We don’t make the world a better place by throwing insults at each other, but by learning from each other.

  • 34 David Colquhoun // Jun 9, 2009 at 17:27

    mcassidy raises an interesting point. The placebo effect can indeed be quite big, but is not the only difficulty in assessing a treatment. The other problem is spontaneous fluctuations and ‘regression to the mean’. It is hardly ever know how important these effects are, and how important placebo effects are.

    To take a more neutral example, homeopathy, the narratives of homeopaths sound strikingly like a description of the natural history of disease. The first remedy may not work, so try a few more. The condition may get worse at first before it gets better. Eventually (if you don’t die) you get better and then attribute that to whatever pill you may be taking at the time. It is all a bit like echinacea which cures your cold in seven days when otherwise it would have taken a week.

    There isn’t even any need to postulate a placebo effect to explain why things that don’t work may appear to be effective.

    The delusions don’t do much harm if your conditions is minor and self-limiting. It becomes a problem when people claim falsely to be able to cure serious diseases, like malaria (homeopaths) or asthma (chiropractors).

  • 35 Quick Update « Science-Based Pharmacy // Jun 11, 2009 at 03:41

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  • 36 The Medicines and Health Regulatory Authority breaks the law? // Jun 11, 2009 at 23:37

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  • 37 Peter Dixon, chair of the General Chiropractic Council, seems to be a bit careless about evidence // Jun 12, 2009 at 23:40

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  • 38 lecanardbeige // Jun 20, 2009 at 19:07

    you should stick to pharmacology and leave medicine alone; you have no competence, just your dogmatic views to criticise NICE or any medical practice; there is little evidence for physiotherapy due to lack of RCT, and if all medicine was RCT and evidence based, paramedic would not be able to use a defibrillator.
    RCTs work for drug, no objection here, they just do not work for anything else. If your narrowminded views were adopted, medicine would take a giant step backward.

  • 39 David Colquhoun // Jun 20, 2009 at 22:27

    I can’t say that I’m vever very impressed by arguments based on authority. Does lecanardbeige really believe that RCTs don’t work for homeopathy? Or perhaps he/she just disbelieves them when they inconveniently come out negative.

    If you had read more carefully what I said, you would know that I agree that the evidence that physiotherapy is effective in low back pain is as thin as the evidence that chiropractic and acupuncture are effective. They appear to be more ot less equally (in)effective. That being the case, why not go for manipulation and forget all the mystical mumbo jumbo.

    Since this post was about chiropractic, I’d like to hear from lecamardbeige his/her assessment of the ‘evidence’ produced by the British Chiropractic Association. And even more I’d like to hear your opinion of the rather good trial by Olafsdottir et al. (2001), “Randomised controlled trial of infantile colic treated with chiropractic spinal manipulation”. Just in case you have never read it, there is a reprint here.

    I await your response with interest.

  • 40 lecanardbeige // Jun 21, 2009 at 07:35

    Those who are pro or against alternative medicine are very selective about the “scientific evidence” that they quote; this debate can go on for either we people throwing at each others convenients RCTs and systematic reviews.
    My problem is with the reliance on RCTs, with their limitations, as the irrefutable truth, also systematic reviews appear to me as a kind of quick fix, a palliative to more expansive scientific research.
    I will give you a simple example: a study published last year http://www.ncbi.nlm.nih.gov/pubmed/18303940 suggest that antidepressants are not much more effective than placebo for treating depression; this of course must contradict all the RCTs conducted for the drugs involved.
    Many clinicians will call that bullshit and will continue to prescribe drugs that they know are effective in improving their patients.
    In 1998, there was 22 millions visit to alternative therapist in the uk (the largest part to acupuncturists, osteopaths, chiropractors and homeopaths): you are never going to sell Evidence Based Medicine to these people, when the indice of satisfaction for alternative medicine is much higher than conventional medicine.
    RCTs have limitations, so have systematic reviews; they are useful for testing drugs, but not so reliable for medical thechniques, they should not be given the status of ultimate proof of anything.
    Rather than relying on this kind of evidence, other methods should be devised for the evaluation of alternative medicine, and also to some conventional medical techniques.
    The RCT (Olafsdottir et al) that you quote is a good example of the limitations of RCTs: small numbers of participant, vague criterias; this should be cited as preliminary findings.

  • 41 David Colquhoun // Jun 21, 2009 at 15:16

    First, the reference to “irrefutable truth” shows that you have little idea of the scientific method. Bertolt Brecht understood it better when he said, in Life of Galileo, “The aim of science is not to open the door to infinite wisdom, but to set a limit to infinite error.”

    Second, I can’t see the point of your citation of the antidepressant study. It has been becoming more and more obvious for years that antidepressants have not lived up to their initial promise (or perhaps I should say their initial hype). There are no contradictions involved, just the gradual accumulation of data in a field that is hard to study. Contrary to what you say, that conclusion is accepted by the clinicians whom I know at least.

    Like all trials, Olafsdottir et al had its limitations, but I asked you to compare them with the far greater limitations in the evidence produced by the British Chiropractic Association. I’m not surprised that you evaded the question.

    You seem very antipathetic to the term evidence-based medicine, So may I ask what you would like to base your medicine on, it it isn’t evidence? What is the alternative? Guess-based medicine? Hunch-based medicine? Myth-based medicine? Authority-based medicine?

  • 42 lecanardbeige // Jun 21, 2009 at 22:22

    There is no need to be sarcastic, you know as well as I do the limitations of RCT and EBM, I do not need to spell them to you.
    I am not against evidence based medicine, I am just pointing out that this evidence is relative (my example of antidepressant for example, the virtues of these drugs were well promoted by pharmaceutical companies on the basis of EBM, this EBM is now obviously questionable.
    EBM and RCT in particular work well for drugs, but not so well for surgical techniques for example, physiotherapy, osteopathy (strange that you attack the chiropractors but leave alone osteopath who do more or less the same thing).
    Sticking to only one level of evidence is not fair, some alternative medicine techniques or practices should be judged on multilevel of evidence, the other problem inherant with your point of view is that EBM, in a conventional medical point of view, refers mostly to the reduction of symptoms (i.e back pain) and does not take in account other qualitative benefits that are often reported by those who had alternative medicine treatment.
    There is also a question of double standard here, as a pharmacologist, why don’t you attack with the same “enthousiasm” the marketing strategies of large pharmaceutical conglomerate who sell millions of tablet on spurious ground since there is a lack of EBM to support it: for example OTC indigestion tablets or cold and cough remedies

  • 43 David Colquhoun // Jun 22, 2009 at 06:54

    lecanardbeige

    I think you have it precisely the wrong way round. It was by doing careful RCTs and meta-analysis that it was possible to reveal the industry’s exaggerated claims for antidepressents. Without them it would have been impossible to debunk those claims convincingly.

    I agree, of course, that evidence is often very inadequate and that, meanwhile, guesses have to be made. The important thing is to recognise that you are guessing.

    I believe it is you who have the double standards, because you seem to believe that because something is labelled ‘alternative’ a lower standard of evidence is acceptable. Al I do is to recommend the same standards for everything.

    In most cases I think it is quite possible to devise adequate controls for surgical and manipulative techniqies. Great ingenuity has gone into devising controls for acupuncture (and ‘real’ acupuncture never seems to differ much from sham). Likewise in the Olafsdottir experiments, the control group of babies was simply held by a nurse for the same length of time that the chiropractor worked on the other group. That seems to be like an excellent control for a crying baby. The result, as you know, was that holding the baby was just as effective as manipulating its spine.

    Concenring ineffective pharmaceutical products, all I can do is to recommend that you read this blog more carefully. I am concerned about ineffective treatments and it really makes no difference whether they are labelled alternative or not.

    As for osteopaths, they are next.

  • 44 lecanardbeige // Jun 22, 2009 at 16:23

    With all due respect, your rigid point of view that only RCT represent the correct level of evidence for alternative medicine (and to other medical interventions I should say) is not shared by a large number of clinicians, and even by the chairman of NICE
    I notice that among the most vocal opposant to CAM, very few of them are doctors or involved in practical medicine; your comment are often unfair to chiropractors, osteopaths or acupuncturists who do not necesarily pretend to cure back pain, but may be very useful indeed in the management of chronic back pain (as accepted by NICE)
    A mixture of Level one and two evidence should be a reasonable way of assessing a number of therapeutic modalities.
    After all, most consumers of CAM (millions of them) pay for their treatment and report a high degree of satisfaction. Are they, in your view a (large) bunch of ignorant idiots because they happen to get better with acupuncture, chiropractice or osteopathy? millions of satisfied customers represent a fair bit of anedoctal evidence in my view; conventional medicine save millions of lives every year, and dispite the fashionable slagging off of the NHS, they do perform “miracles” everyday, but these heroic feats are not always evidence based.
    Even if I agree with you that some claims made by some alternative medicine practitioners are ludicrous, I think your black or white reasoning is out of place, multi-valued lines of evidence are closer to the reality of life than an Aristotelian two- valued judgement.

  • 45 David Colquhoun // Jun 22, 2009 at 18:24

    lecanardbeige

    I think that the reason that you are having such difficulty in understanding the importance of RCTs is that you are failing to understand the enormous difficulty in establishing causality.
    Your really should read my post about bacon and cancer on that topic.    The Taubes article referred to there is really good.  You should also try books like Baussell or Singh & Ernst which explain in simple terms how very easy it is to fool yourself about causality.That applies not only to people who have a financial interest in being fooled, but also to patients who desperately want relief.

    I should also point out that the guidance was not written by the chairman of NICE, but by a group that was dominated by manipulative people.

    It is true that my interests lie in statistics (both single molecules and clinical trials) but you are quite wrong to suppose that clinical people support any more tham I do.  The first signatory of our 2006 letter was Michael Baum, a breast cancer surgeon who has taken a special interest in palliative care. Many of the other signatories were clinicians too.  Try his Samuel Gee lecture. It is quite brilliant and at the end it gets quite moving as he points out the cruelty of giving false hopes to desperate patients. There is a human cost to believing unreliable evidence.

  • 46 lecanardbeige // Jun 24, 2009 at 07:44

    I have no problem understanding the value of RCT, when applied to testing drugs for medical purpose; I explored a bit the links you mentioned, and I can see that coming from statistics, you understand numbers better than people.
    According to your gospel, RCT is the only answer to life, the universe and everything.
    The word Gospel come to mind because your quasi religious fervor in wanting to eliminate alternative medicine, you are a crusader, if you had your way, we would return to the good old days of the inquisition.
    So much for scientific objectivity.
    Your aim is to debunk, it is entirely negative, the real sceptic is open minded and do not reject anything a priory.
    The way you select, in your answers a few arguments that go along with your views while ignoring everything else that go against is such a clear demonstration of your lack of objectivity.
    In short, you and your friends are a little cohort of pseudo-sceptics screaming for attention.
    A quick search of medical litterature would give you a wealth of good scientific papers indicating that some of the alternative medicines (acupuncture, osteopathy, herbal medicine for example) are effective in a number of conditions.
    If RCT is the only reference, then it is good bye to physiotherapy, psychotherapy, counselling, a large number of well tried medical intervention, and even reanimation techniques (any RCT on mouth to mouth recussitation?
    The world of science does not need this kind of attitude, I find it disappointing.

    Have you either considered a course in anger management?

  • 47 David Colquhoun // Jun 24, 2009 at 08:12

    It’d a bit rich for an alternative medicine advocate to accuse me of being “quasi-religious”, because one of the most obvious characteristics of quacks is their quasi-religious belief in any myth that takes their fancy. Like religious people they seem to have no problem in believing mutually contradictory things and like religions they suffer from dreadful internecine warfare between rival sects of the ‘same’ religion. The bitterness that exists between various sects of homeopaths or chiropractors leaves skeptics in the shade (an example here).

    I and others have searched the literature a great deal more thoroughly than you, and you really are in no position to criticise on that score, having brushed aside the one good trial of chiropractic for colic (Olafsdottir et al.), apparently because you doin’t like its conclusions.

    I’ll admit that I do rather welcome comments here from alternative medicine advocates. Their comments are usually so obviously unreasonable that they help to make the case for reason.

    If you have read the Baussell’s book (and I’ll bet a small amount that you haven’t) you might have noticed one of my favourite quotations.

    “But why should nonscientists care one iota about something as esoteric as causal inference? I believe that the answer to this question is because the making of causal inferences is part of our job description as Homo Sapiens.”

  • 48 phayes // Jun 24, 2009 at 09:57

    “In short, you and your friends are a little cohort of pseudo-sceptics…”

    Herberts?

  • 49 lecanardbeige // Jun 26, 2009 at 08:09

    “But why should nonscientists care one iota about something as esoteric as causal inference? I believe that the answer to this question is because the making of causal inferences is part of our job description as Homo Sapiens”

    this is laughable, pathetic drivel

    Come back Descartes, all is forgiven!

  • 50 David Colquhoun // Jun 26, 2009 at 08:36

    lecanardbeiige
    Wonderful!
    You have just illustrated better than I ever could have done that you have failed totally to understand everything that has happened since the enlightenment.

    Sadly you seem to be stuck in the dark ages. You are quite free to have any delusions you want about truth and falsehood. The only thing that scares me is that you might be treating sick people.

  • 51 Allo V Psycho // Jun 26, 2009 at 12:30

    lecanardbeige:
    I’m a little puzled by your response: “this is laughable, pathetic drivel. Come back Descartes, all is forgiven”.
    First, while one might argue that Baussel is mistaken, it is a point worth considering. Humans do draw causal inferences all the time: is this a trait programmed by evolution, and if so how and why? Often, the simple ‘causal’ inferences we draw are mistaken: are there common categories of mistake that we can identify and hence avoid? (this is particularly important in medicine and other complex biological systems). Conversely, can we identify succesful rules for inference drawing (the process known as “science”) and apply them more widely? In what sense exactly are such questions “drivel”?
    And I do not quite understand the reference to Descartes. Studies of inference might certainly make reference to Descartes, but as far as I am aware his thinking was not at odds in any way with the proposition that Baussel makes. Can you guide me further on this? I would be very sorry indeed to think that your comments were just meaningless abuse.

  • 52 lecanardbeige // Jun 26, 2009 at 21:56

    “But why should nonscientists care one iota about something as esoteric as causal inference? I believe that the answer to this question is because the making of causal inferences is part of our job description as Homo Sapiens”

    what evidence is there to back up such a statement; statistical causative inference?

    the world is not ruled by statistic; did Newton discover th e law of gravity by statistical causative inference? statistic give a limited view of the reality based on the few criterias chosen, it does not necessarily represent the real world.
    I understand a statistician having a preference for statistics but it does not answers all the questions

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